Healthcare Provider Details

I. General information

NPI: 1942795448
Provider Name (Legal Business Name): MAGDELON GILBERT RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAGDELON RADER

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 GORDON COOPER DR
SHAWNEE OK
74801-9007
US

IV. Provider business mailing address

1601 GORDON COOPER DR
SHAWNEE OK
74801-9002
US

V. Phone/Fax

Practice location:
  • Phone: 405-395-9303
  • Fax: 405-395-9305
Mailing address:
  • Phone: 405-395-9303
  • Fax: 405-395-9305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2280
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: